INITIAL EVALUATION

February 24, 2019

NAME: S.E
AGE: 74 years old
SEX: Female
MARITAL STATUS: Single
ADDRESS: Barangay Malalim Batangas City
OCCUPATION: None
RELIGION: Roman Catholic
NATIONALITY: Filipino
HANDEDNESS: Right
REFERRING PHYSICIAN: Dr. Mandigma
PHYSIATRIST: -
DATE OF REFERRAL: -
DATE OF CONSULTATION: October 09, 2018
DATE OF EVALUATION: February 24, 2019
TYPE OF PATIENT: outpatient
DIAGNOSIS: R Mild Stroke
INFORMANT: Patient
RELIABILITY: Reliable

S:
CHIEF COMPLAINT: “Nahihirapan akong maglakad gamit ang tungkod ko at
nanghihina ang aking kaliwang paa kaya hindi na ako makapunta sa aming bakuran
upang makapaggamas“.

Pt’s GOAL: “Makalakad ako ng maayos at makapaggamas na ako sa bakuran namin.”

HPI:
5 mos PTE when the pt took a rest after pulling out grass in her backyard for ~ 3 hrs, she
suddenly felt numbness in her left hand, she didn’t know that it was already an episode of
stroke, she massaged her hand hoping that it would ease the numbness sensation. The
symptoms persist until she consulted the doctor after a week. After some time, her mouth
hanged down on the left side, she had difficulty in speech and swallowing and there was an
observable change in her gait. That exact day, she was brought by her sister to the United
Doctors of St. Camillus De Lellis Hospital. She was brought to the Emergency Room and there
she underwent CT scan (see ancillary procedure). She stayed in the hospital for two days and
after further assessment (blood chemistry, hepato-biliary tree ultrasound), she was eventually
discharged and was prescribed by appropriate medications most specifically for her HTN and
stroke. (see present medication) She was advised to take the medication OD to help in keeping
her blood pressure to normal range and prevent other complications. Pt was advised to undergo
PT rehabilitation d/t weakness and stiffness of her L UE and difficulty in walking.
 3 mons PTE pt undergo PT rehabilitation for 5 times per week (~ 3hours) and with
regular check up every 3 months for her HTN. To monitor progression, she was given an
aluminium adjustable quad cane to ambulate and her medicine dosage was reduced to 3
tablets/day. In the middle of the month, her therapy sessions ceased because her attending
therapist who happened to be her relative migrated due to work matters. There are
improvements specially on her face and L UE.
1 week after her recent check-up, her drug dosage was lessen (Irbesartan from 300 mg
to 150 mg, Clopidogrel rosuvastatin from 150mg to 75 mg) which she still strictly take once
daily, 7 times per week. Her complaint of L hand numbness was gone but she still complains of
her ambulation and walking difficulties.
At present, Pt still have her maintenance medications to be taken OD. Pt presents
difficulty in ambulating from sitting to standing and walking at a considerable distance
approximately 10 meters. There is a presence of pitting edema on her L foot, weakness of left
LE mm, impaired balance while in prolonged hours of standing and walking. She uses her quad
cane in ambulating with difficulty. She has follow up check up on March. Pt is willing to undergo
PT rehabilitation.

Ancillary procedures
Procedure Date Findings
CT scan October 09, 2018 There is no intracranial
bleed or acute infarct seen
There is a brain atrophy as
evidence by widened sulci,
fissures, cisterns and
ventricles

Presents Medications:
Medication Dosage Indication
Irbesartan (Irbevex) 150 mg, 3x a day Angiotensin II Receptor
blocker
Clopidogrel rosuvastatin 75mg/10mg, 3x a day Anti-platelet,
antihypeerlipidemia

PMHx:

 (+) HTN, Controlled

 (-) DM
 (-) Cardiopulmonary problems
FHx:

 (+) HTN, Paternal side

 (+) DM, Paternal side

PSEHx:

 Pt is high-school graduate
 Pt lives c her 3 sisters in a 2-storey, tiled house.
 Pt’s bedroom was 10 meters away from their bathroom.
 Pt used to have home responsibilities such as cleaning the house and washing
clothes.
 Pt’s past time is watching tv for ~ 2hrs/day.
 Pt is non-smoker and non-drinker.
 Pt regularly eats vegetables and rice (~ 1 cup/meal)
 Pt frequently uses plastic deckchair.
 Pt’s bed is of standard height.
 Pt is financially stable
 Pt is of type B personality
 Pt’s family is supportive for her future PT rehab sessions.

O:
VS:
BP: 110/70 mmHg
PR: 74 bpm
RR: 22 rpm
Temp: 36.2°𝐶
Interpretation: VS are WNL

Inspection:

● Alert, coherent, cooperative

● Ectomorph
● Ambulatory c alluminum adjustable quad cane with modified 4-point gait (R)
● (+) Dry Skin on B LE
● (+) Wound in L dorsal foot (~1cm)
● (+) Minimal swelling on L foot
● (+) Anterior pelvic tilt
● (-) Mm atrophy
● (-) Erythema
● (-) LE deformity

Interpretation: The above findings are complication of R Mild Stroke d/t stopped
intervention.
Palpation:

● Normothermic
● (+) Tightness on B cervical lateral flexors, L cervical rotators and L Dorsiflexor
mm
● (+) Gr.1 pitting edema on L foot
● Gr. 2 mm tone of L biceps and quadriceps mm
● Gr. 4 mm tone of L dorsiflexor mm
● (-) Mm guarding
● (-) Crepitus
● (-) Tenderness

Interpretation: The above findings are complication of R Mild Stroke d/t stopped
intervention.

Anthropometric measurement
LGM
LE Landmark L R/N Difference
Below lateral 27 cm 24 cm 3 cm
malleolus
2 inches above 20.5 cm 20.5 cm 0
lateral malleolus
4 inches above 22.5 cm 22 cm .5 cm
lateral malleolus
Interpretation: Pt has minimal swelling on her L ankle d/t prolonged sitting position and
difficulty in ambulation 2⁰ to R Mild Stroke

NEUROLOGIC ASSESSMENT:

MENTAL STATUS
Test for orientation
Questions:
Person
 What is your name?
 How old are you?
  When were you born?
 What is the name of your husband?

Place
 Do you know where are you right now?
 What city or town do you live in?
 What is your address?

Time
 What is today’s date?
 What time is it?
 Is it morning or afternoon?

Circumstances
 What happened to you?
 What kind of place is this?

Findings: Pt was able to answer 12 questions correctly.

Test for attention
Specific test:
 Recite the days of the week
 Recite the month in chronological order
 Count 1 to 20
Findings: Pt was able to correctly follow all the instructions. Pt is attentive.

Test for memory

Questions:
Short term
 What did you eat this morning?
 What did you eat for lunch today?
 What time did you woke up this morning?
 What was the last text you sent?

Long term
 What are the names of your mother and father?

Findings: Pt was able to answer all the questions accurately.

Significance: loss of memory or unconsciousness is common manifestation in R Mild
Stroke
Test for fund of knowledge
 Who is the first Philippine president?
 What is the Philippines’ national anthem?

Findings: Pt was able to answer all the questions correctly. Pt’s fund of knowledge is not
impaired.
Test for abstract thinking
 Explain “Give a man a fish and you feed him for a day; teach a man to fish and
you feed him for a lifetime”

Findings: Pt was able to explain the proverb well. Abstract thinking is not impaired.

Tests for understanding of spoken language

 Repetition of spoken sentences
 Naming
- Name the parts of the body
- Names of her sisters living at her house

Findings: The pt was able to understand spoken language.

Interpretation: Pt cognitive status is not impaired, impaired cognitive status is common
in R Mild Stroke.
SENSORY AX
a. Superficial Sensation
a. STD: Pin for pain, cotton for light touch, and blunt side of neurohammer
for deep pressure.
Findings: Pt has intact superficial sensation
Significance: Deep sensory impairments are common in R Mild Stroke

b. Deep Sensation
a. Proprioception and Kinesthesis
Findings: Pt has intact proprioception and kinesthesia in B UE and B LE
b. Vibration perception
Findings: Pt has intact vibration perception
Significance: Deep sensory impairments are common in R Mild Stroke
c. Cortical Sensation
a. Graphestasia
Findings: Pt has intact cortical sensation
Significance: Cortical sensation affectation is common in R Mild Stroke
Tone Assessment:

Gr. 4 Affected part rigid in flexion or extension

Modified Ashworth Scale:

Gr. 0 No increase in muscle tone

Gr. 1 Slight increase in muscle tone, manifested by a catch and release or by minimal
resistance at the end of ROM when affected part is moved in flexion or extension

Gr. 1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance
throughout the remainder (less than half) of the ROM

Gr. 2 More marked increase in muscle tone through most of the ROM, but affected part easily
moved

Gr. 3 Considerable increase in muscle tone, passive movement difficult

 Gr 2 mm tone of L biceps and quadriceps mm

 Gr. 4 mm tone of L dorsiflexor mm

Interpretation: increase in mm tone is common in R Mild Stroke.

DTR
R L

++ ++ Legend:
++ ++ 0 - Areflexia
+ - Hyporeflexia
++ ++ ++ - Normoflexia
+++ - Hyperreflexia
++ 0 ++++ clonus

Note: Deep Tendon Reflex of L Achilles Tendon were not assessed d/t gr.1 pitting
edema.

Pathologic Reflexes
(-) Clonus, L ankle
Interpretation: There was no clonus reflex of L ankle d/t gr. 4 mm tone of L ankle DF.
Special Test
 Not pertinent

CRANIAL NERVE Ax
 CN IIV - mm weakness on L side of the face
 CN X- difficulty in swallowing

Interpretation: cranial nerves affectation is common in R Mild Stroke

COORDINATION Test
 Finger-thumb test
 Finger-to-nose test
 Hand “Flip” test
 Hand- thigh test

Proprioception test
 Proprioceptive finger-nose test
 Proprioceptive movement test
 Proprioceptive space test

Equilibrium tests
 Standing with normal BOS
 Standing with feet together
 Tandem walking
 Walking along straight line
 Walking sideways, backwards or sidestepping

Non-equilibrium test
 Finger-to-nose test
 Finger-to-therapist’s finger
 Finger-to-finger
 Alternate nose-to-finger
 Finger opposition
  Pronation-supination
 Tapping hand
 Tapping foot
 Toe to examiner’s finger

Findings: Pt was able to do all the tests and presents without any coordination problem.
Significance: Coordination problems are common in R Mild Stroke

ROM
All joints of neck, trunk, BUE and BLE are WNL except:
AROM PROM Difference

Jt L R L R N AR PROM End-feel
movements OM

Cervical 0-10⁰ 0-10⁰ 0-15⁰ 0-15⁰ 0-45⁰ 0⁰ 0⁰ FIRM

lateral flexion

Cervical 0-10⁰ 0-60⁰ 0-15⁰ 0-60⁰ 0-60⁰ 50⁰ 45⁰ FIRM

rotation
Hip Flexion 0-55⁰ 0-70⁰ 0-60⁰ 0-80⁰ 0-120⁰ 15⁰ 20⁰ FIRM
Knee Flexion 0-110⁰ 0- 0-115⁰ 0- 0-135⁰ 25⁰ 20⁰ FIRM
135⁰ 135⁰
Ankle 0-15⁰ 0-15⁰ 0-15⁰ 0-15⁰ 0-20⁰ 0⁰ 0⁰ FIRM
Dorsiflexion
Ankle 0-10⁰ 0-45⁰ 0-10⁰ 0-50⁰ 0-50⁰ 35⁰ 40⁰ FIRM
Plantarflexio
n

Interpretation: mm tightness is common complication of R Mild Stroke

MMT
All UE and LE muscles are graded 5/5 except:
(L) Sh flexors: 4/5
® Hip flexors: 3+
(L) Hip flexors: 3/5
(B) Plantarflexors: 2+

Interpretation: Mm weakness is a common complication of R Mild Stroke and results to

difficulty in ambulation.

Postural Assessment:
 No other pertinent findings

Balance
Sitting balance:
• Static: With eyes open (EO), pt was able to maintain position independently up to 5
minutes with minimal postural tremor; with eyes closed (EC), truncal ataxia is
pronounced
• Dynamic: With EO, able to weight shift to left and right to about 40% of limits of
stability (LOS); with EC, experiences loss of balance (LOB) with minimal weight
shifts
Standing balance:
• Static: Able to maintain standing position with min assist × 1 for up to 3 minutes;
during standing, patient is unable to maintain centered alignment; demonstrates
moderate postural tremor; with EC, sway is increased dramatically but patient
does not lose her balance
• Dynamic: Able to weight shift or step without bilateral handhold

Findings: Pt was able to maintain her sitting and standing balance

Significance: Sitting and standing balance disturbance is common in elderly and pt c R
Mild Stroke

Functional assessment
 Stroke Specific Quality of Life Scale (SS-QOL)

Interpretation: a score of 102 in Stroke Specific Quality of Life Scale (SS-QOL)

considered significant ADL disability. Pt minimal to moderate difficulty in performing
ADLs and IADLs.
A:
PT Impression: Pt has R ACA, mild stroke as evidenced by difficulty in waking d/t
weakness, minimal swelling of her L foot and increase mm tone mm tone of L biceps,
quadriceps and B dorsiflexor mm d/t complication of stopped PT interventions.
Rehab Potential: Pt has fair prognosis considering her age and for being highly
motivated to comply with the rehab treatment.

P:
Problem List:
1. Difficulty in waking d/t weakness of her L foot
2. Gr.1 pitting edema on L foot
3. Dry skin on BLE
4. Tightness on B cervical lateral flexors, L cervical rotator and L Dorsiflexor mm
5. Mm weakness of B hip flexor and ankle PF, L hip flexor
6. Pt minimal to moderate difficulty in performing ADLs and IADLs

LTG: (3 mos.)
1. Pt. will be able to walk s difficulty using a unilateral quad cane and do her IADLs
(maintenance of their backyard)
STG: (2 wks, 6 sessions)

1. Pt will be able to walk c minimal to no difficulty using a unilateral quad cane.

2. Pt will eliminate minimal swelling on L foot
3. Pt will be able to moisturize BLE
4. Pt will increase ROM of her B cervical lateral flexors, L cervical rotator and L
Dorsiflexor mm
5. Pt will increase mm strength of B hip flexor and ankle PF, L hip flexor
6. Pt will be able to perform ADLs and IADLs s minimal to no difficulty.

PT Plan:
1. Gait training using an aluminum adjustable quad cane x modified 4-point gait x
level and elevated surfaces x OD
2. Ankle pumps c L LE elevated x supine x 10 reps x 2 sets x OD x 3x/week
3. PROME/AROME stretching program x all joints motion of BUE and BLE x 10
reps x 2 sets x bid x 3x/week
4. Mechanical strengthening using ankle weights x Gravity-minimal position x B
ankle PF mm x 10 reps x 3 sets x 3x/week
5. Mechanical strengthening using ankle weights x Gravity-resisted position x B hip
flexors mm x 10 reps x 3 sets x 3x/week
HEP:
1. Ankle pumps c L LE elevated x supine x 10 reps x 2 sets x OD x 3x/week
2. Apply lotion every after bathing, daily
3. Proper positioning strategies

Prepared by:
Delgado, Ela Jamina Antonio
Mendez, Julia Sacha Marie Mendoza